New Medicaid rules put states in a tough position

States will have to allocate resources and ingenuity to implement all of the proposals outlined in the new CMS Medicaid managed-care rules, experts say.

A slew of new quality standards outlined in the 653-page proposed CMS rules are meant to modernize Medicaidmanaged-care regulations and improve quality of care. But cash-strapped state agencies might not be able to manage the load.

“Some states have smaller staffs and it's going to be a heavier lift for them,” said Pam Coleman, a senior consultant at Sellers Dorsey and former Texas deputy Medicaid director.

States are expected to take a streamlined approach to ensuring quality of care by standardized their requirements to match those requested of exchange and Medicare Advantage plans.

That includes ensuring plans go through an accreditation process scheduled at least once every three years. States should then publicize information on approved companies on their Medicaid website.

The rules also call for the creation of some type of quality ranking or star system for managed plans similar to those already in place for Medicare and exchange plans.

It's possible the rules will pose headaches for states not so much from a resource perspective, but because they may discourage plans from wanting to offer managed Medicaid plans, said Gail Wilensky, former Medicaid program director under President George H.W. Bush.

States like Florida, Maryland New York, Texas and several others relying on Medicaid managed care already appear to have some version of accreditation in place, making it less of a heavy lift, according to Tom Dehner, a managing principal at consulting firm Health Management Associates, and a former Medicaid program director for Massachusetts.

A plan-ranking system may take more work, but since the infrastructure is already there for health plans in exchanges and Medicare Advantage plans, that shouldn't be too difficult either, Dehner said.

But others say the devil is in the details.

“The requirements placed on the states cannot be so prescriptive as to limit innovation or constrain the state in designing a system that meets the needs of the individual states,” said Billy Millwee, a former Texas Medicaid director and managing principal at Sellers Dorsey. “CMS will need to allow states ramp-up time. While the rules provide one level of guidance, there will be a host of policies that will need to be developed and implemented.”

“Quality measures are a good thing and people are already moving in the right direction,” said Matt Salo, executive director of the National Association of Medicaid Directors. “Moving forward, it's going to be about finding a balance with the CMS (to support) the direction some are already going in.”